# Scaling and root planing (D4341 / D4342) — payer documentation requirements

> What documentation do dental payers require for scaling and root planing (D4341 / D4342) claims? The published rules, payer by payer, with a direct link to every source document.

URL: https://dentovio.com/dental-claim-documentation/d4341-scaling-and-root-planing

Last verified: 2026-08-28

Dentovio is an independent publisher — not a dental payer, the ADA, or any state dental board. These summaries describe the payers' published clinical-review and documentation criteria; individual plan contracts still control coverage, frequencies, and exclusions, and payers revise policy documents on their own schedules. Educational billing reference only, not billing, legal, or clinical advice. CDT codes are referenced by number only; CDT is the American Dental Association's copyrighted code set and this page does not reproduce ADA descriptors.

## Direct answer

Payer documentation thresholds for scaling and root planing genuinely differ: Cigna's published guidelines pay at pocket depths of 4 mm or deeper with radiographic bone loss, Aetna's claim-documentation guidelines state that documented 5–8 mm pockets generally determine benefits, and DentaQuest's Colorado manual requires radiographic bone loss of 2.5 mm or greater from the CEJ and rejects PSR screening outright. Submit 6-point periodontal charting, diagnostic radiographs showing bone loss, and quadrant tooth counts that match the code — then confirm the current rule in the payer's own policy document linked on this page.

## Why these claims get denied

SRP is among the most-reviewed procedure families in dental claims. Payers deny or downcode it when the submitted periodontal charting does not show their pocket-depth threshold, when radiographs do not demonstrate bone loss, or when the quadrant does not contain enough qualifying teeth.

## Requirements by payer

### Aetna

Aetna's DCPB041 requires 6-point periodontal charting with bleeding on probing, full-mouth radiographs, and chart notes documenting appointment duration and anesthetic for scaling and root planing claims.

- Periodontal charting that records pocket depths at 6 points per tooth, with indications of bleeding on probing
- Full-mouth radiographs or digital images (unannotated/unmarked)
- Chart notes documenting the duration of the appointment and the type and amount of local anesthetic administered
- The claim-documentation guidelines add root surface calculus and radiographic bone loss as benefit determinants
- Published threshold: Aetna's claim-documentation guidelines state that, in general, documented 5–8 mm pockets determine D4341/D4342 benefits
- Frequency / timing: DCPB041 positions D4341/D4342 for moderate to severe periodontitis, distinct from gingivitis scaling (D4346)

Sources:

- [Aetna DCPB041 — Scaling and Root Planing](https://www.aetna.com/health-care-professionals/clinical-policy-bulletins/dental-clinical-policy-bulletins/DCPB041.html)
- [Aetna Dental Clinical Policy Bulletins index](https://www.aetna.com/health-care-professionals/clinical-policy-bulletins/dental-clinical-policy-bulletins.html)
- [Aetna Dental and Oral Surgery Claim Documentation Guidelines (PDF)](https://www.aetna.com/content/dam/aetna/pdfs/families/Dental-Claim-Documentation-Guidelines.pdf)

### Cigna

Cigna's PERIO-16 pays scaling and root planing when submitted periodontal charting and radiographs confirm pocket depths of 4 mm or deeper plus radiographic bone loss, with 4 or more qualifying teeth per quadrant for D4341.

- Periodontal charting and radiographic images confirming periodontal pocket depths of 4 mm or deeper
- Radiographic evidence of bone loss
- D4341 requires 4 or more qualifying teeth in the quadrant (D4342 covers 1–3 teeth)
- Published threshold: Pocket depths 4 mm or deeper, plus radiographic bone loss
- Frequency / timing: Denied when the same office retreats the same quadrant within 24 months

Sources:

- [Cigna Dental Coverage Determination Guidelines — DPPO, 2026 edition (PDF)](https://campaigns.cigna.com/static/campaigns-cigna-com/docs/dental-hcpemails/Clinical%20Documents/Cigna%20Dental%20Coverage%20Determination%20Guidelines%20-%20DPPO%20-%202026%20-%20Final.pdf)
- [Cigna Dental Coverage Determination Guidelines — DHMO, 2026 edition (PDF)](https://static.cigna.com/assets/chcp/pdf/resourceLibrary/dental/CignaDentalCoverageDeterminationGuidelinesDHMO2026.pdf)

### Delta Dental (Delta Dental Ins. enterprise)

Delta Dental Ins. clinical criteria require radiographs within 12 months showing alveolar crest loss beyond the normal 1–1.5 mm distance to the CEJ, plus periodontal charting within the past 12 months and chart notes with the periodontal stage.

- Bitewing or periapical radiographs taken within 12 months showing loss of alveolar crest height beyond the normal 1–1.5 millimeter distance to the cementoenamel junction (CEJ)
- Periodontal charting completed within the past 12 months
- Chart notes documenting the periodontal stage
- Published threshold: Radiographic alveolar crest loss beyond the normal 1–1.5 mm CEJ distance

Sources:

- [Delta Dental Ins. Clinical Criteria / Utilization Management (PDF)](https://www1.deltadentalins.com/content/dam/ddins/en/pdf/dentists/provider-tools/clinical-criteria-utilization-management.pdf)
- [Delta Dental Federal Government Programs Dental Office Handbook 2026 (PDF)](https://www1.deltadentalins.com/content/dam/ddins/en/pdf/affiliate-sites/common/dental-office-handbook-2026.pdf)
- [Delta Dental of North Carolina — Dentist Handbook, January 1, 2026 (PDF)](https://deltadentalnc.com/hubfs/Delta%20Dental%20Dentist%20Handbook%202026.pdf)

### MetLife

MetLife's Preferred Dentist Program manual requires recent, dated pretreatment periodontal charting plus a full-mouth X-ray or bitewings for D4341/D4342, and defines a quadrant as 4 or more teeth with quadrant indicators required.

- Recent, dated pretreatment periodontal charting
- Full-mouth X-ray or bitewings, if available
- Quadrant = 4 or more teeth; quadrant indicators required on the claim

Sources:

- [MetLife Preferred Dentist Program Resource Manual (archived public PDF)](https://web.archive.org/web/20230317041442/https://eforms.metlife.com/wcm8/PDFFiles/28922.pdf)
- [MetLife dental provider portal (current rules; login required)](https://www.metdental.com)

### United Concordia

United Concordia's SRP claims guide requires full-mouth series X-rays with high resolution and contrast demonstrating bone loss, full 6-point diagnostic charting, and individual tooth numbers (not just quadrants) for D4342.

- Full-mouth series X-rays with high resolution and contrast demonstrating bone loss
- Full diagnostic charting showing the pocket depth at six key points around each tooth
- Individual tooth numbers — not just quadrant indicators — for D4342
- Published threshold: Radiographically demonstrable bone loss

Sources:

- [United Concordia — Scaling and Root Planing Claims: Getting It Right (PDF)](https://www.unitedconcordia.com/content/dam/ucd/en/commercial/website/docs/transcripts/Scaling%20and%20Root%20Planing%20Claims%20Getting%20it%20Right.pdf)
- [United Concordia help center — SRP claims policy](https://www.unitedconcordia.com/help-center/dental-providers/what-is-your-policy-on-claims-for-scaling-and-roo-planing)

### DentaQuest (Medicaid/CHIP administrator)

DentaQuest's Colorado ORM (§15.09) requires complete periodontal charting with abnormal pocket depths in multiple sites (PSR screening is not acceptable), the AAP case type, and radiographic bone loss of 2.5 mm or greater from the CEJ.

- Complete periodontal charting indicating abnormal pocket depths in multiple sites — PSR is not acceptable
- AAP case type documented in the charting
- Radiographic evidence of noticeable loss of bone support: 2.5 mm or greater from the CEJ
- Published threshold: Radiographic bone loss ≥ 2.5 mm from the CEJ
- Frequency / timing: Once per quadrant per 3 years; maximum 2 quadrants per date of service (Colorado ORM)

Sources:

- [DentaQuest Colorado Health First Office Reference Manual (PDF)](https://www.dentaquest.com/content/dam/dentaquest/en/providers/colorado/co-health-first-office-reference-manual.pdf)
- [DentaQuest Indiana ORM via Humana (PDF)](https://www.dentaquest.com/content/dam/dentaquest/en/providers/indiana/in-humana-office-reference-manual.pdf.coredownload.inline.pdf)
- [DentaQuest Kentucky Medicaid manual via Anthem (PDF)](https://providers.anthem.com/docs/gpp/KY_CAID_DentaQuestManual.pdf)

## Payers without public criteria for this procedure

- Guardian: Provider portal login required. Guardian publishes no open documentation criteria for SRP, crowns, or buildups. Treat any third-party summary of Guardian rules as unverified and confirm in the portal before relying on it. Policy library: [Guardian provider toolkit](https://www.guardianlife.com/providers/toolkit)
- MCNA Dental (Medicaid/CHIP administrator): Public — no login. MCNA's manuals are public and versioned, but Dentovio has not yet extracted MCNA's own per-procedure criteria text; use the state manual directly for D4341 and crown criteria. MCNA also points providers to the ADA's public SRP claims-submission guide. Policy library: [MCNA Texas Medicaid and CHIP Provider Manual](https://manuals.mcna.net/texas)

## Related

- [All payer documentation requirements](https://dentovio.com/dental-claim-documentation/index.html.md)
- [Dental claim denial codes](https://dentovio.com/dental-claim-denial-codes/index.html.md)
- [Dental insurance prompt-pay laws by state](https://dentovio.com/dental-prompt-pay-laws/index.html.md)